Supporting Statement

SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION

A. Justification.

1. Need and Use

The administrative requirements for information collected is Chapter 13, Section 3, Paragraph 4.2, of the TRICARE Operations Manual 6010.51-M (copy attached).

Completed forms are placed in the appeal or hearing case file. The forms document, for anyone reviewing the case file, the professional qualifications of the medical professional who reviewed the case file. Having a qualified medical professional provide medical and peer review is essential to the appeal and hearing process. If the form is not placed in the case file, a person reviewing the file will not have access to the qualifications of the medical professional.

2. Purpose and users of the information

Users of the information contained in the Professional Qualification Medical/Peer Reviewers forms are appealing parties and their representatives (such as a TRICARE beneficiary or an attorney representing a TRICARE beneficiary), medical providers of care associated with an appeal or hearing case, and anyone authorized access to the appeal or hearing case file. The agency uses the information contained in the Professional Qualification Medical/Peer Reviewers form as evidence of the qualifications of the medical professional who provided medical and peer review of the case file.

3. Improved Information Techniques

This collection process involves the medical professional filling out and submitting a simple, two-page form. Respondents are required to complete the Professional Qualifications Medical/Peer Reviewers form only once and update it only if their qualifications change. There are no technological collection techniques that would enhance this simple and efficient collection process.

4. Duplication and Similar Information

There is no duplication. The medical professional fills out the form once with updates it as necessary. Similar information is not readily available. In some instances, the medical professional will have available a resume or curriculum vitae which can be included in the case file as a substitute for the Professional Qualifications Medical/Peer Reviewers form; however, resumes and curricula vitae do not always contain the required information and are not always available. The form provides a consistent means of obtaining and listing the required information. If the resume or curriculum vitae contains the required information, the medical professional will not be required to complete the form.

5. Small Business

This collection of information does not have a significant impact on small businesses or other entities.

6. Less Frequent Collections

If the form is not placed in the case file, a person reviewing the file will not have access to the qualifications of the medical professional which will impede the functioning of the appeal and hearing process. Collection is done on a one-time basis with data updated as necessary. Data cannot be collected on a less frequent basis.

7. Special Circumstances

There are no special circumstances that require the collection to be conducted in a manner inconsistent with the guidelines in 5 CFR 1320.5 (d) (2).

8. Federal Register Notice and Consultations

The Federal Register Notice for this collection of information was published May 3, 2007 (Vol. 72, No. 85, p. 24569 & 24570). Copy attached. No public comments were received.

9. Payment/Gift to Respondents

There will be no payment or gifts provided to respondents.

10. Confidentiality

The information requested is not confidential.

11. Sensitive Questions

Questions of a sensitive nature are not asked.

12. Burden Estimate (hours)

The number of respondents is estimated not to exceed 60 per year. The estimate is based on there being no more than 10 contractors providing medical professional reviews and cumulatively employing no more than 100 reviewers; and no more than 60 new or updated Professional Qualification Medical/Peer Reviewers forms required (i.e., many forms, resumes, and curricula vitae have been submitted and are on file). Time necessary for the medical professional to complete and sign the form is estimated to be 0.25 hours. If medical professional’s time is valued at $50.00 per hour, cost to the professional will be $12.50. The annual burden hours calculated as follows:

Respondents: 60

Response Time: 0.25

Response Frequency: (one time)

Burden Hours: 15 hours*

*(60 x 0.25 hours = 15 hours)

Respondent Cost: 60 x $12.50 = $750

13. Cost to Respondents

There will be no additional cost to respondents.

14. Cost to Federal Government

The only administrative processing by TRICARE Management Activity employee is to place the form in a compendium of forms upon its receipt and then to photocopy and place the form in a case file as needed. Each of these two actions takes approximately one minute.

Mailing of form to respondent: (60 x $.41) = $24.60. TRICARE Management Activity Employee Administrative Processing Cost: $.43 (per minute wage of a GS-8, Step 9 employee $55,441 Denver yearly salary divided by 2087 (work hours/year) = $25.61/ hour divided by 60 minutes = $.43 per minute) x 120 copies (60 copies filed in the compendium and 60 copies photocopied and placed in case files) = $51.60 per year.

Photocopying of form: (2 pages x 60 copies x $.02 per page) = $2.40

Total: $78.60

15. Changes in Burden

This is an extension of a previously approved collection.

16. Publication/Tabulation

There are no plans to publish or tabulate the information collected.

17. Expiration Date

Approval is not sought for avoiding display of the expiration date for OMB approval.

18. Certification Statement

There are no exceptions to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-1.

B. Collections of Information Employing Statistical Methods

Statistical methods are not employed for collection of this information.